Decreasing in physical strength

5.Growth and development: What statement is true?

Developmental task: Milestones are age related achievements

6. Safety: what is the major thing we need to teach the young adult group?

Automobile safety

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7.What action would you see a nurse utilize in reflection to improve clinical decision making?

Care plan, experience

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8. Using Erickson’s theory: a 9-year-old that has difficulty making friends and doesn’t get chosen to play in sports, receives very little positive feedback from teachers or parents. According to Erickson theory failure at this stage of development results in

Feelings of inferiority

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9. You are assessing a 58-year-old woman you will most likely find that this patient is experiencing which physiological change that is normal?

Decreased mental status

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10. Statement regarding self-medication administration, what would require you to follow up teaching?

Pt says she will just take the pills all at once, so she doesn’t forget. That requires follow up

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11. Safety: what body mechanics would the nurse incorporate in to patient care?

Feet flat, legs wide apart, knees should be flexed (bent)

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12. Which of the following interventions is likely to have the most impact on reducing friction when repositioning an immobile client?

Using a lift sheet

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13. You have a client that tends to take smaller steps, feet are kept closer together what is happening or could happen?

increase clients risk for injury

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14. Symptoms a nurse should assess, for a patient that is sleep deprived:

irritaion and confusion

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15. Nurses are protected by what law in the scope of practice during an emergency?

Good Samaritan law

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16. Nursing diagnosis: a patient with irritability, being sleepy during the day, and can’t sleep at night. What nursing diagnosis would you chose?

insomnia

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17. Document notation: which are the most appropriate notations used according to the guidelines when charting client care?

Answer not given: pick the most thorough notation

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18. Pressure ulcers: how are they primarily formed?

ischemic

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19. Why do we irrigate wounds?

Remove debris

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20. A patient has a midsternal wound, she is afraid because she is coughing, and the wound is still fresh. What is she going to do for the cough?

use pillow

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21. Which nursing entry is most complete in describing the patients wound?

Approximated, staging, no blanching or redness, drainage

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22. Nursing diagnosis for ineffective breathing pattern to a patient care plan, which sleep condition caused the nurse to assign the nursing diagnosis?

sleep apnea

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23. What is the primary reason for an older adult to have a pressure ulcer on the elbow compared to someone that is middle aged?

Thin skin, subcutaneous tissue

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24. What statement shows that the nurse has the greatest insight into the need to manage the risk factors that contribute to pressure ulcers?

Decreasing the amount of time that we have her on each side

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25. What standard of care applies to the student nurse conduct when providing normally performed care?

Students provide the same standard care as someone that is licensed

26

A doctor’s order is not legible, and you guess what the order says, later you discover that you read it wrong. Who is responsible for the error?

You as the nurse. If an order is not legible you should confirm with the doctor

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27. Informed consent indicates:

Pt voluntarily signed, and understands the risk and benefits

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28. Pick legally appropriate notation:

No answer given. Make sure you read them and chose the one that covers all aspects

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29. As a nurse you have a legal and ethical obligation to find information on pain. Which client information collected by the nurse reflects a systemic response to a wound infection?

Hypothermic

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30. Stages of pressure ulcers: intact skin and may include changes in the following skin temperature, tissue consistency and or pain what stage is it on?

stage 1

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31. What does the Braden’s scale evaluate?

risk factor for skin breakdown

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32. Stages of pressure ulcers: You have a patient with a sacral pressure ulcer, tissue over the sacrum is dark, hard, and is adhering to the wounds edges. What stage?

Unstageable

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33. You have a patient that is sleep deprived is finally sleeping, your priority nursing intervention is what?

34. As a nurse you should intervene when a patient care tech does what?

Gives a sleep deprived patient coffee before bed

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35. How will HIPPA effect a patient care?

HIPPA provides greater control of your personal health records

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36. What needs to be happening for a patient to get a pressure ulcer?

Tissue ischemia, poor nourishment, immobility

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37. You are assessing a 50-year-old patient who states she is having pain and redness under her right breast. What action is best?

Thorough assessment

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38. Kohlberg: moral development and the child’s ability to integrate what?

Right from wrong

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39. Which surgical scenario of a surgical patient is most indicative of critical thinking?

What has worked, pharmacological or non-pharmacological

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40. As a nurse, what indicates application of critical thinking to make the best clinical decisions?

ADPIE, nursing process

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41. You are critically thinking in the stage of evaluation, what action will the nurse take?

Reviewing interventions to see if it worked

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42. Patient tells you he is having pain a 9 out of 10 and his medication dose is not due for another hour. What should the nurse do first?

You can give the medication, and if you cannot give the med explore other options

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43. A nurse is using professional standards to influence clinical decisions. What is the rationale to the nurse’s action?

Uses critical thinking for the highest level of quality nursing care

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44. Pressure Ulcer stages: as a nurse you are visiting a long-term care unit as the wound care nurse. You are monitoring a patient with a Stage 3 pressure ulcer, wound seems to be healing, has healthy tissue observed. How would the nurse chart this finding?

Healthy stage 3 pressure ulcer

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45. You are taking care of a patient who has a full thickness repair, what type of tissue will the nurse expect to observe when the wound is healing?

Granulation (healthy tissue)

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46. you have a patient that had a laparoscopic appendectomy. What type of healing will the nurse focus on in the care plan?

Primary care

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47. You are taking care of a patient with a big dressing and he said, “something is giving way.” What does that mean?

Dehiscence

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48. What lab test data would be important for the nurse to check for a patient with an ulcer?

albumin

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49. You are doing a head to toe assessment on a patent who has potential for skin breakdown of some sort. What is the assessment priority?

Pressure point

50

50. You are taking care of a patient with a surgical incision that eviscerates. What are you going to do?

51. you are a school nurse and you are called to the gym for an injured student, student is crying and in severe pain with a malformed fracture of the lower leg. What kind of assessment will you perform?

Inspecting with light palpitation

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52. If you are examining a female with discharge what position are you going to put her in?

lithotomy

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53. Pt with pneumonia you hear high pitched continuous musical sound:

wheezing

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54. Before you do a physical assessment on a patient you should do first?

Psychological preparation of the patient

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55. You are assessing a child that fell off his bike there is an inflammatory response what do you see?